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State Apology Delivered by An Taoiseach, Leo Varadkar T.D., Dáil Éireann, Tuesday 22 October 2019.

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Ceann Comhairle,

As Taoiseach, on behalf of the State, I apologise to the women and their loved ones who suffered from a litany of failures in how cervical screening in our country operated over many years.  

I do so having met and listened to many of those affected and I do so guided by the Scally Inquiry report.

Today we say sorry to those whose lives were shattered, those whose lives were destroyed, and those whose lives could have been different.

We know that cervical screening programmes cannot detect all cancers, however we acknowledge the many failures that have taken place.

 

We are sorry for:                 

-failures of clinical governance

-failures of leadership and management

-failure to tell the whole truth and do so in a timely manner

-the humiliation, disrespect and deceit

-the false reassurance

-the attempts to play down the seriousness of this debacle.

 

We apologise to those who survived and still bear the scars, both physically and mentally.  As do their families.  

We apologise to those who are here in our presence.  To those watching from home who have kept it to themselves.   We apologise to those passed on and who cannot be here.

We acknowledge the failure that took place with CervicalCheck. 

Today’s apology is too late for some who were affected.  For others it will never be enough.

Today’s apology is offered to all the people the State let down.  And to the families who paid the price for those failings.

 

A broken service, broken promises, broken lives –a debacle that left a country heartbroken.  A system that was doomed to fail. 

We apologise: to our wives, our daughters, our sisters, our mothers. 

To the men who lost the centre of their lives and who every day have to try and pick up the pieces.  The single fathers and grandparents.  

To the children who will always have a gaping hole in their lives.

To all those grieving for what has been taken from them.  The happy days that will never be. 

A State apology may not provide closure, but I hope it will help to heal.     

I have met with some of you and your families and I have heard your stories, told to me with dignity, courage and integrity.  Families turned upside down.  

The grief of losing loved ones.

The guilt of those who survived, thinking they were the ‘lucky ones’.  Those who have lost their jobs and careers, their ability to have children, their feeling of self-worth.   Who feel mutilated inside, who feel they have robbed their partner out of the possibility of having a child.  A future stolen from them.  

A State apology will not repair all that has been broken, nor restore all that has been lost, but we can make it count for something. 

Thanks to Dr Scally’s three reports into CervicalCheck we have discovered a lot of truths.  

 

We now know a lot of facts.

Some things we will never know.

But what we do know we can act on and make sure this doesn’t happen again.

The Government accepted all of the recommendations that were set out in Dr. Scally’s reports and all will be implemented.

Now, in the words of Vicky Phelan, I want something good to come out of all of this. 

 

Speaking as a doctor, as well as a politician, a brother and a son, I know the lessons we must learn.

We need a better culture in our health service, one that treats patients with respect and always tells the truth.  One that is never paternalistic - doctor doesn’t always know best.  We must always share full information with our patients, admit mistakes, and put the person first.  There is no information about a patient that the patient should not know. No patient should ever feel stonewalled by the system.  We should never act or fail to act out of fear of litigation or recrimination.

The involvement of patient advocates like Stephen Teap and Lorraine Walsh and others has shaped and enhanced our response.

We have revised the Open Disclosure policy so that in future patients will have full knowledge about their care and treatment.  They will be informed when things go wrong, met to discuss what happened, and receive a sincere apology if an error was made while caring for them.  Above all, patients will be treated with compassion and empathy.

The new Patient Safety Bill will provide for the mandatory reporting of serious reportable events and will establish a statutory duty of candour.

Soon, we will establish a new Independent Patient Safety Council.  The first task of the Council will be to undertake a detailed review of the existing policies on Open Disclosure across the whole healthcare landscape.

As a State we aim to make cervical cancer a very rare disease in Ireland.   It is almost impossible to eradicate a disease but we can get very close.

 

So, we are switching to primary HPV screening, and Ireland will become one of the first countries in the world to adopt this new more accurate screening test.  

We are also extending the ever developing HPV vaccine to boys.

We are educating and informing parents about the benefits of the vaccine.

We are investing in better facilities in Ireland like a national cervical screening laboratory, in conjunction with the Coombe.  This enhanced facility will take some time to develop but will provide a better balance between public and private provision of laboratory services to the cervical screening programme, always putting quality ahead of cost.   It will bring more testing back to Ireland. 

We need to restore confidence in screening.  

We also need to listen to those who have suffered and learn from their stories so we can find justice. 

In July we established the CervicalCheck Tribunal, a statutory tribunal to deal with the issue of liability in CervicalCheck cases.  It won’t be perfect but it will be quicker, with a dedicated judge and independent experts, less adversarial than court.

Women will still have the right to go to court.

We established an ex-gratia compensation scheme for those affected by the non-disclosure of the Cervical Check audit to provide financial compensation without the need to go to court.  

However this was never about money.  This was about accountability, discovering what happened and why, providing justice and finding peace.  It was about making a meaningful acknowledgement of what happened, and give an assurance that this won’t happen again to anyone else.

We have seen further errors in some of the laboratories since the publication of the Scally Report, causing confusion and anxiety, so we have more to do to restore confidence.  We are determined to do so. 

 

Ceann Comhairle,

What happened to so many women and families should not have happened.  While every case was not negligence, every case was a lost opportunity for an earlier diagnosis and treatment.   

It was a failure of our health service, State, its agencies, systems and culture.

We’ve found out the truth and the facts. 

We’re making changes to put things right.  

We need to restore trust and repair relationships.

On behalf of the Government and the State, I am sorry it happened.  And I apologise to all those hurt or wronged.  We vow to make sure it never happens again.